MEDICARE: JAYASRI INDARAM MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207K00000X	Allergy & Immunology Physician	193883	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1255331302
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAYASRI INDARAM MD

Provider Business Mailing Address
First Line	:	10 CARRIAGE DR
Second Line	:
City	:	OLD WESTBURY
State	:	NY
Zip	:	11568-1323
Country	:	US
Telephone Number	:	516-655-3327
Fax Number	:	516-801-2070

Provider Business Practice Location Address
First Line	:	9709 101ST AVE
Second Line	:
City	:	OZONE PARK
State	:	NY
Zip	:	11416-2523
Country	:	US
Telephone Number	:	718-641-5555
Fax Number	:	718-641-6677

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/29/2005
Last Update Date	:	12/05/2013

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